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Wednesday, March 9, 2011

Pregnant with cancer, women struggle to heal for two

Pregnant with cancer, women struggle to heal for two

With a black tweed hat on her bald head and a purple blouse stretched over her big belly, Lisa Peterson Bender leans forward in the clinic chair, the better to see the ultrasound images of her unborn daughter.

Up on the screen, the tiny girl opens her mouth, furls her fingers and kicks her legs in vibrant 3-D as a technician confirms that, for now, all appears well with the baby being carried by a woman who has cancer.

“There’s the toes: You can see all five of them,” says ultrasonographer Carla Knapp, pointing to a small, clearly visible foot as she conducts the exam at the University of Minnesota’s Maternal-Fetal Medicine Center. “Your baby is a happy baby in there today, I’ll tell you that.”

For Lisa and her husband, Ryan, both 32, the relief is palpable. Lisa was barely 11 weeks into her first pregnancy last summer — young, healthy and expecting to sail through the experience — when a suspicious lump in her right breast was diagnosed as malignant.

“We were devastated,” says Lisa, who told TODAY.com she got the call as she was driving home from work. “I went through every form of emotion. I was yelling in the car, ‘No, no, no!’ "

For the past eight months, Lisa, a city planner, and Ryan, a software engineer, have navigated a new world of terrible dilemmas: How do you treat cancer to save the mother — and still protect the unborn baby?

1 in 1,000 pregnant women has cancer It’s a growing problem that now affects as many as 1 in every 1,000 pregnant women, with about 3,500 diagnosed in the United States each year. As more women delay childbirth until they’re older, the incidence of cancer during pregnancy, particularly breast cancer, is going up.

A 2009 study of Swedish women of childbearing age found that the incidence of breast cancer associated with pregnancy more than doubled between 1963 and 2002, partly because of births to older mothers, suggest the authors, whose work was published in the journal Obstetrics and Gynecology.

Researchers now estimate that between 7 percent and 15 percent of breast cancers in pre-menopausal women occur in those who are pregnant, said Dr. Elyce Cardonick, an associate professor of obstetrics and gynecology at Cooper University Hospital in Camden, N.J.

“It’s not going to be as rare as we once believed,” says Cardonick, who created the Cancer and Pregnancy Registry in 1997 to collect enough data to detect trends.

As the number of the cases grows, however, so do the options for treatment. Instead of terminating pregnancy, once almost universally recommended, or waiting to treat the disease until after childbirth, perhaps allowing the cancer to grow, more women are urged to battle the cancer head-on.

“You treat them the same,” says Cardonick. “You do what would be indicated if she were not pregnant.”

That can be a shocking concept for modern pregnant women who avoid coffee, wine, even soft cheese and lunchmeat, in the effort to nurture healthy babies. Suddenly, when they have cancer, surgery and drug therapy are not only OK, they're necessary.

“I had given up caffeine, I was trying to eat really organic food and then I was going to do chemo?’” says Lisa, a marathoner and cyclist. “It’s so psychologically hard to reconcile putting poison in your body."

Lisa, who was diagnosed with Stage II breast cancer, opted for both surgery and chemotherapy, undergoing four three-week rounds of drug treatment during her second trimester. While she struggled with the idea of putting harsh drugs in her body — “The purpose of chemotherapy is to stop cells from growing,” she points out — she knew she had to try to halt the disease even as she protected the baby.

“I was very committed to this pregnancy,” explains Lisa, who was slow to embrace parenthood, but discovered a fierce protectiveness that surprised even her husband.

"She has this strong maternal instinct that I hadn't even seen until now," Ryan says, adding later: "I want to make sure the baby has a mommy."

Their daughter is due March 17; the couple has picked out a family name for the child, but they're not sharing it until she's born.

‘A little bump’ leads to diagnosis In some ways, Lisa was fortunate. Her cancer was diagnosed quickly, within weeks of her husband noticing “a little bump” in her right breast and then her own detection of another, larger lump.

But many women are not. Changes in their bodies caused by pregnancy can mask the symptoms of cancer, said Dr. Douglas Yee, director of the Masonic Cancer Center at the University of Minnesota.

“Delay in diagnosis among pregnant women is a problem,” he says.

Lisa also was fortunate to find immediate support for her decision to continue the pregnancy. That’s not always the case, even now, notes Cardonick.

Cardonick was spurred to start the cancer registry by Patty Sosnader, a pregnant woman whose doctor sent her to an ethics board and to mental health counselors when she refused to terminate her pregnancy after a diagnosis of Hodgkin’s disease.

“To me, I guess I’m not an advocate of abortion. I just couldn’t see terminating the pregnancy,” says Sosnader, 46, a mother of three in Worcester, Pa., who turned to Cardonick for help. This month, her youngest son, Brenden, the child she bore while battling cancer, turns 13.

Of the 282 women logged in Cardonick’s cancer registry so far, 67 were advised to terminate their pregnancies and 13 actually did so.Current research recommends that most pregnancies continue despite cancer, but some doctors — about 20 percent — continue to advise termination, Cardonick says.

Doctors who haven’t treated a pregnant patient with cancer, or those who fear legal liability, are more likely to advise women to end pregnancies. Instead, the decision should be the woman's based on informed advice, she says.

"There are definitely people in the registry where termination was the right choice for them," Cardonick says.

Treatment dilemmas loom large Once cancer patients decide to continue their pregnancies, more dilemmas loom. The type of cancer, the stage at which it’s diagnosed and the length of pregnancy all dictate the course of treatment.

In many cases, surgery is necessary. Lisa, for instance, had her walnut-sized malignancy removed quickly, within a month of diagnosis. The surgery was a success; the tumor was removed and the margins surrounding were clear of cancer. Most pregnant women can tolerate surgery well; however, they're advised to wait until after birth to undergo reconstructive procedures.

Deciding about chemotherapy is more complicated. Research shows that certain chemotherapy drugs, such as Lisa's treatments of Cytoxan and Ardriamycin, are safe during pregnancy because the drug molecules are too large to pass through the placenta. Unlike other toxins, they're prevented from reaching the baby.

Other drugs, however, such as Herceptin, have received black-box warnings forbidding use during pregnancy because of their toxicity, even though they may be able to battle cancer better.

As difficult as it was to use the chemo, Lisa says she found comfort in ultrasound images that showed the baby has tiny wisps of hair.

"For me, it just symbolized that she had been protected from the chemo, because I lost most of my hair during the treatment," she says. "The fact that she had hair made me feel like she was OK, that my body had done its job."

Chemo appears safe in second trimester Lisa also learned that at certain points in pregnancy, chemotherapy does not appear to cause problems for developing fetuses. Children exposed to chemo in the first trimester of pregnancy, when organ formation occurs, are more likely to be miscarried, to die in the womb or to have serious abnormalities.

But those who are treated during the second trimester show no more problems than the general population, according to a study of 231 women in Cardonick's registry who were tracked over 13 years, published in the American Journal of Oncology in 2009.

Further, growing research suggests that women treated for cancer while pregnant may do no worse than non-pregnant women, and perhaps even better. A 2009 study of 75 pregnant women and 150 non-pregnant breast cancer patients by the University of Texas M.D. Anderson Cancer Center found that nearly 74 percent of the pregnant women survived disease-free for five years, compared with about 56 percent of the women who weren’t pregnant. Overall survival was higher, too, the research showed.

Still, there’s no certainty in any of this, doctors and patients emphasize. Even now, research remains limited about the outcomes for pregnant women with cancer. Data are even more scant regarding the long-term effects of chemotherapy treatment during pregnancy on the children who are born.

Lisa did the best she could, reading everything available on cancer in pregnancy and seeking out a second opinion at the prestigious Mayo Clinic. In the end, though, doctors there said the choices were hers and Ryan’s to make.

“They said no one can tell you what to do,” she says. “The most important thing is that you’re at peace with your decision.”

‘I'm kind of out of control.’ Finding that peace hasn’t been easy. Juggling the changes of pregnancy with the worries of cancer while still working and running a household have been hard, Lisa says.

It's taken a toll on Ryan, too, forcing him to shoulder responsibilities and worries that the couple — world travelers, married just three years — never imagined.

“I’m kind of out of control and I can’t really do a lot about it except make her mashed potatoes with butter after chemo,” he says, noting that the early days were the most difficult. “It was a really tough time, there were so many unknowns, too many unknowns.”

“I have survivors all across the country checking in on me,” she says. “It’s amazing to see women who have survived for decades. When I see cancer survivors with their teenage kids, I get really emotional.”

With the delivery of their baby just days away, the Benders feel like they’ve endured the worst of it. Lisa is set to resume chemotherapy a week after the baby is born, with treatment followed by radiation and hormonal drugs for up to five years.

She’s already talking about another baby, and doctors say it’s possible the pair could have more children. For now, though, the goal is to simply meet the tiny girl they've struggled so hard to keep.

“I think we’re just going to be really thankful,” says Lisa. “I just feel like she’s such a survivor already.”

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